How open is ‘open’ enrollment?

As the Trump administration attacks the Affordable Care Act, access for limited-English speakers has remained surprisingly steady.

In October, it begins. Globo, a Philadelphia-area translation firm, starts to hire. And come November, according to CEO Gene Schriver, interpreter demand “gets crazy.” That’s because the company’s largest client is the U.S. Centers for Medicare & Medicaid Services (CMS), the federal agency that oversees Affordable Care Act (ACA) enrollment for 11 states and the District of Columbia. If you don’t speak English and you call CMS to sign up, CMS calls Globo.

In 2017, CMS requested interpreters for 190 different languages, placing more than 120,000 calls for its 10 most-requested languages alone — a total bill of around $5 million. These calls, Schriver said, are on top of conversations that bilingual CMS employees have with limited-English speakers directly.

According to the U.S. Census, more than 60 million Americans don’t use English at home. That’s 20.78 percent of the country. So for these people, just how “open” is open enrollment, when the sign up is not originally in their language?

While 58.2 percent of limited-English individuals speak the language “well,” that doesn’t mean they necessarily understand the language of health care — a lexicon that even baffles native English speakers. That’s because no person can know every word in any language. As people, our vocabularies center on certain areas, the subjects we encounter most in work and life. Your average Manhattanite likely has a limited farming vocabulary, but tell a rural American you live in “the city,” and she’ll probably ask which one. This, said Don DePalma, chief strategy officer for the research firm Common Sense Advisory, is why professional translators and interpreters “have some expertise or knowledge about specific topics or sectors – like legal, medical devices, retail” but don’t work across all domains. No matter how fluent you may be, even native speakers can’t know everything.

For the why-don’t-they-learn-English? advocates, this is the answer: Signing up for health insurance is complicated, no matter what language(s) you speak. That’s why, when the Trump administration killed ads promoting open enrollment January 2017, Mara Youdelman, managing attorney for the National Health Law Program (NHeLP), was concerned that access for limited-English speakers would die as well — not just because it meant the end of Spanish-language commercials, but because such enrollees “are often harder-to-target individuals because the language is a barrier.”

So nearly two years later, did Youdelman’s fear come true?

Under the Obama administration, Youdelman said, NHeLP had an active role in making sure open enrollment was available in all languages. But this work stopped “with the incoming of the Trump administration,” she said, “which has set about to sabotage and undermine the ACA every place they can.” When asked to detail how this “sabotage” she described has had an impact on limited-English speakers, she said, “I can’t point and specifically say that this administration changed a policy that reduced language access.”

While many have justifiably accused the president and his administration of being racist in other ways, ACA language access is actually one area in which statistics show services for people of color haven’t changed.

“Our first year [with Trump] in place,” Schriver said, “we were concerned that the administration moved to limit all extensions, to essentially cut all funds for advertising for open enrollment — things like that were going to significantly curb the number of calls to CMS — but it actually didn't change it all.” In fact, he said when the Trump administration shortened the open enrollment period, which now runs from November 1 to December 15, call volume actually spiked, with requests that had been previously stretched over two months now coming “in greater numbers in a shorter period of time.”

While CMS denied The Outline’s open records request and didn’t respond to interview requests, Schriver said that demand wouldn’t be so strong unless CMS wanted to ensure limited-English Americans still have access.

In the world of medical interpreting, far too many clients don’t care about equal access, ignoring Title VI of the Civil Rights Act of 1964 requirements to provide limited-English patients with free interpreters. In fact, it’s not uncommon for hospitals and government-funded facilities to sign contracts with translation providers just so they can claim interpreting is available. But these organizations never intend to buy it — the paperwork just goes in a file to show Uncle Sam.

As Chris Carter, the former president of the Association of Language Companies and managing director of Globo competitor aLanguage Bank, told me, health care organizations “usually wait until they are audited” before providing services. These audits come from the Department of Justice or through the Affordable Care Act itself, as ACA Section 1557 outlines $70,000 fines for hospitals that don’t provide language access. Even still, Schriver said when facilities don’t care, “Their agents end up hanging up on [people] or they dispose of them in other ways.”

Whether interpreter access actually results in more people having insurance is difficult to gauge. Per the Commonwealth Fund, a private foundation that promotes health care access, the percentage of foreign born Latinxs without insurance has remained relatively stable since 2013, when an overwhelming 47 percent were uninsured. This was one year before ACA began and two years before CMS signed its current interpreting contract. From February to March of this year, half were still uninsured. Foreign-born Latinxs remain the people group least likely to have insurance, comparing to only 13 percent of U.S.-born Latinxs uninsured this year.

Certainly, native-level English is one indicator separating those born in this country from those who were not. Immigration or citizenship status, Youdelman said, is another, as you must be in the country legally in order to enroll under ACA. And, in light of the Trump administration’s recent threats to deport those accessing government services, Schriver said that “There's a large fear of the unknown from being even connected to the system. I think in the Latino and the Hispanic community in general, first generation — whether they're here legally or illegally — feel like anything that touches the government might threaten whether they're going to be able to remain in the country. So they stay disenfranchised in many cases, even when they're here legally.”

“There’s a lot of pieces in the puzzle,” Youdelman said. “I definitely think language access is a piece.” If you look at the 10 states where CMS works with interpreters, eight — Connecticut, Maryland, Massachusetts, Minnesota, New York, Rhode Island, Vermont, and Washington — boast some of the lowest uninsured rates in the nation, with more than 90 percent of residents insured. But out of the 11 states where more than 15 percent of people don’t have it — including Texas with its 8.22 million limited-English residents — Idaho is the only one that participates in CMS’s interpreting program.

Buying health insurance, Schriver said, is “like buying anything. If you can't buy it in your language, you don't know what you're buying. It's impossible to do it.” Statistically, DePalma agreed: According to a survey his company conducted, people are 1.3 times more likely to buy any service or product when information about it is available in their language.

As for putting enrollment in terms every American can understand, in addition to providing interpreters, CMS has translated HealthCare.gov into Spanish and Youdelman said that enrollment forms are available in 15 languages. Meanwhile, Globo’s still hiring: Schriver said that interpreter demand “stays crazy” not just through open enrollment, but through the end of January.